April Annals Audio posted!

Apologies for the delay, but here it is, better than ever! Highlights:

-Advance directives and EMS cardiac arrests in Oregon: do they agree?
-Organ donation after cardiac arrest? Ethical and practical issues
-Is outpatient ED care profitable?
-Reimbursement effect of the ACA
-A Standardized Mortality Rate for EM
-Bells Palsy in the ED: how often do we have it right?
-Does it matter which thrombolytic or dose, for ischemic stroke?

And much more…. Email anytime at annalsaudio@acep.org.

D&A

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Why I Made Emergency Medicine My Career by Mark Baker, MD, FACEP

 

What other jobs allow you to stay up all night long, party with crazy people, and get paid for it?

That’s what I like to say every New Year’s Eve. New Year’s Eve is my favorite shift, and it’s because of the people.

They are what keep me going in this career: the people, the crazy people, and I don’t mean just the patients.

Docs, nurses and techs all have to be a little bit loony to enjoy this job as well. It is the best job in the world! I come to work not knowing exactly what I will be doing, and even while working we never know what’s going to happen next.

Time-bombs are lurking in the humdrum of the daily routine. Our job is to identify them and defuse them. This keeps us on our toes, and this keeps me intrigued. When I can solve a medical puzzle, I am intellectually rewarded. When I can help someone I am gratified. When I can make a child smile I am happy. I can’t figure everything out or everybody out but I can sure have fun trying! This is why I continue my career of emergency medicine.

Why did I make it my career in the first place?

It looked exciting, isn’t that why we all chose it?

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QIPS Section Webinar Features PQRS Updates

Please register for the next Quality Improvement & Patient Safety (QIPS) “All Section Webinar,” which will feature a presentation from ACEP leaders Dennis Beck, MD, FACEP & Rick Newell, MD, FACEP on the 2014 Updates to the CMS Physician Quality Reporting System (PQRS) and the Physician Value-Based Payment Modifier (VBM) with input from Mike Granovsky, MD, FACEP.

This webinar will take place 11:00 a.m. EDT on Tuesday, April 1.

  • Learn about CMS new requirements for the 2014 PQRS incentive and the 2016 payment adjustment and the PQRS measure set as follows. The penalty for failure to report PQRS has increased from 1.5% to 2%, and non-reporters will also be penalized with an additional 2% penalty for the new Value-Based Modifier.
  • Learn which measures to report in order to earn the PQRS Incentives CMS requires eligible professionals to report 9 Measures Across 3 NQS Domains via the claims-based or registry reporting mechanisms
  • Understand the Measures Applicability Validation (MAV) process, which will allow CMS to determine whether an eligible professional should have reported quality data codes for additional measures.

Please register here or click on the link below and be sure to add the event to your calendar after registering.
https://attendee.gotowebinar.com/register/1561548761077304066

Tuesday, April 1 at 11:00 a.m. ET
Dial in Number: 1-877-366-0711
Participant Code: 14253069
Mute/Unmute: *6

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March audio is (and has been) posted!

Sorry for the late notice, but the March audio summary is up. Highlights:

-Gestalt in the ED for diagnosing PE and ACS: we’re overdoing it
-Radiation exposure among zero and near-zero risk patients: we’re overdoing that too
-Editorial: Should patients pay when asking for unnecessary testing?
-Topical anesthesia for mouth ulcers in kids: a RCT
-EHRs in the ED: associated with more imaging, medication, and testing of all kinds
-Health Info Exchanges: need to be better
-Central line infection prevention: tougher than it sounds

Email any time, and thanks for listening as always,
D&A

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Dr. Seth R. Gemme, ACEP Clinical Policies Committee Reviews AAN Concussion Guidelines

By: Seth R. Gemme, MD

The ACEP Clinical Policies Committee regularly reviews guidelines published by other organizations and professional societies.  Periodically, new guidelines are identified on topics with particular relevance to the clinical practice of emergency medicine. This article highlights recommendations for the education, recognition, and management of concussions, published by the American Academy of Neurology in June, 2013. 

Concussions have become a popular topic of concern in the media and with the public over the last several years as many amateur and professional athletes have had career ending head injuries. According to the Centers for Disease Control and Prevention, concussion visits to the emergency department have increased, likely as a result of the increased awareness. Thus there is a need for a better understanding of the neurocognitive pathology and risks associated with a concussion.

In June of 2013, the American Academy of Neurology (AAN) published a guideline focusing on the risk factors of concussion, clinical features associated with worse outcome, and management. They graded the literature since 1955 using a modified version of the GRADE working group process and made recommendations using a modified Delphi process.

Various risk factors were investigated. There was not enough evidence that age made a difference in risk of concussion. With regards to gender, men make up the majority of concussions, likely due to more men playing contact sports, with the greatest risk in American football and Australian rugby. Females were found to be at higher risk if participating in soccer or basketball versus other sports. There is no evidence that mouth guards protect athletes from concussion in any sport. In American football, there is no evidence regarding superiority of one type of football helmet in preventing concussion. Other factors associated with greater risk include a BMI of greater than 27 or training for less than three hours per week. In addition, it is likely that there is an increased risk for repeat concussion within 10 days of the initial concussion.

Clinical features associated with severe or prolonged early postconcussion impairments include a history of prior concussion, early post-traumatic headache, fatigue or fogginess at the time of diagnosis, early amnesia, altered mental status or disorientation, or younger age. Increasing concussion exposure is a risk factor for chronic neurobehavioral impairment in a broad range of professional contact sports but evidence is insufficient in amateur sports of whether or not prior concussion exposure increases chronic cognitive impairment.

The AAN recommends that school-based professionals, athletes, and parents be educated by a designated licensed health care provider (LHCP) about concussions in general and associated risks.  A LHCP is one who has acquired skills and knowledge relevant to the evaluation and management of sport concussions and is practicing within his or her scope of practice. This can be either a sideline or clinical LHCP. AAN also recommends that assessment tools be used by the sideline LHCP and those results be made available to the clinical LHCP. One sideline tool discussed is the Standardized Assessment of Concussion which can be administered in 6-minutes and assesses orientation, immediate memory, concentration and delayed recall. Other sideline tools discussed include the Post-Concussion Symptom Scale and the Graded Symptom Checklist which also may be administered in a short time interval and identify concussion.

Two important grade B recommendations are that team personnel should immediately remove any athlete from play with a suspected concussion and that the athlete not be allowed to return until evaluated by the LHCP. It is also recommended that no player should return to play until a LHCP has deemed the concussion to be resolved after being off all medications.  A graded process for return of play is recommended with consideration given for formal neurocognitive testing. This makes it essential that patients with a concussion who are discharged from the ED follow up with a LHCP in the outpatient setting.

Per this guideline, in the diagnosis of a concussion, head CT scan is not indicated unless other more serious complications are possible.  Factors they deemed as risks in their recommendation include loss of consciousness, post-traumatic amnesia, persistence of a GCS<15, focal neurologic deficit, clinical skull fracture, or clinical deterioration. The guideline does not go into any more detail with regards to imaging.

As an athlete gets older and enters more competitive sports, there is a high level of pressure to get back to play.  With continued awareness programs and through this guideline, physicians, parents, coaches, and athletes may be able to reduce risk of recurrent concussions and help prevent long-term neurobehavioral impairment.

Reference
Summary of evidence-based guideline update: Evaluation and management of concussion in sports.  Neurology. June 11, 2013;80(24):2250-2257.

Dr. Gemme is a resident in emergency medicine at Alpert Medical School of Brown University, and is the 2013-2014 EMRA Representative to the ACEP Clinical Policies Committee. 

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Critical Care Certification for Emergency Physicians – The “Grandfather” Pathway

Dr. Francis L. Counselman

By Francis L. Counselman, M.D., CPE, FACEP

In the August 2013 issue of ACEP News, the various pathways available to current and future emergency medicine residency graduates to achieve Critical Care Medicine (CCM) certification through fellowship training were reviewed. In this issue, the options available to ABEM diplomates who completed a Critical Care Medicine fellowship prior to the establishment of the current pathways will be discussed.

First, there is no “practice only” pathway for Critical Care Medicine. All CCM certification requires successful completion of ACGME-accredited CCM fellowship training, and practice of Critical Care Medicine. Secondly, there is no “grandfather” pathway available through the American Board of Surgery (ABS) for Surgical Critical Care. This decision by ABS was made for internal policy consistency, and there are no exceptions. Finally, like all “grandfather” pathways, there is a time-limited window during which one can apply for certification. Please make yourself aware of these dates.

American Board of Internal
Medicine (ABIM) Critical Care Medicine
For Internal Medicine-Critical Care Medicine (IM-CCM), the “grandfather” pathway requires both the completion of a 24-month CCM fellowship and the practice of Critical Care Medicine. This pathway is scheduled to close on June 30, 2016. For the 24-month CCM fellowship to count, it must meet one of the following criteria: a) an ACGME-accredited IM-CCM fellowship completed prior to September 21, 2011; b) an unaccredited IM-CCM fellowship that subsequently became ACGME-accredited on or before December 31, 1992; or c) an ACGME-accredited fellowship in another critical care specialty (i.e., Surgical CCM, Anesthesiology CCM).

The second component, the practice portion, is a little more complicated. The EM applicant must have met the practice criteria as of the date on which the application is submitted to ABEM. For at least three years, not necessarily contiguous, of the five years prior to submitting the application (including the 12 months immediately prior to submission), the applicant must have met one of the following criteria: a) 40% of post-training clinical practice time in the practice of CCM; or b) 25% of total post-training professional time in the practice of CCM.

Finally, for those ABEM diplomates who completed an ACGME-accredited IM-CCM fellowship in the recent past (i.e., between September 21, 2008, and September 20, 2011) criteria can be met if, during 60% of the time between completing fellowship training and applying for certification, the applicant completed one of the following: a) 40% of post-training clinical practice in the practice of CCM or; b) 25% of total post-training professional time in the practice of CCM.  For example, if an applicant completed fellowship training on June 30, 2011, and applied for certification on July 1, 2013, 60% of the time (i.e., 24 months) would be 14.4 months.  So, during that 14.4-month period between completion of fellowship training and application submission, the applicant must meet either the 40% or 25% criterion, as described above.

Physicians whose total practice exceeds 40 hours per week may use 40 hours as the denominator for the “40%” or “25%” calculations for either of the above scenarios.

American Board of Anesthesiology (ABA)
Critical Care Medicine (ACCM)
ABEM diplomates seeking certification through the “grandfather” pathway must have completed both an ACGME-accredited ACCM fellowship program (one or two years in length) and the CCM practice component by the time of application submission, and no later than June 30, 2018; this is the final date of the last application period within the grandfather pathway. The ACCM fellowship training must have been started prior to July 1, 2013.  In order for the fellowship program to count, it must have been ACGME-accredited at the time of the applicant’s training; it does not count if the fellowship subsequently became accredited.

For the practice component, during the two years immediately preceding the application submission, the applicant must have completed one of the following: a) 40% of post-training clinical practice time in the practice of CCM, or; b) 25% of total post-training professional time in the practice of CCM. For either calculation, if total practice time exceeds 40 hours per week, 40 hours may be used as the denominator for the “40%” or “25%” calculation.

Additional Details
For both the IM-CCM and ACCM eligibility criteria, the “practice of CCM” is strictly defined. An acceptable practice must occur in a designated critical care unit.  Caring for critically ill patients in the ED does not count toward the practice component. For more detail on what constitutes the practice of CCM, please visit the ABEM website at www.abem.org

For all CCM subspecialty pathways, the ABEM diplomate must: meet the requirements of the ABEM Maintenance of Certifications (MOC) program at the time of application and throughout the certification process; be in compliance with the ABEM Policy on Medical Licensure; and provide information about someone who can independently verify the physician’s clinical competence in CCM, successful completion of ACGME-accredited CCM fellowship training, and the physician’s practice of CCM. No opportunities for CCM certification existed just two years ago for emergency physicians, but we now have three pathways going forward, including two grandfather pathways. It is a very exciting time for emergency physicians interested in Critical Care Medicine. The opportunities that now exist are the direct result of the hard work, persistence, and energy of many of our colleagues. To all involved, “Thank you!”

Dr. Counselman is Chairman of the Department of Emergency Medicine at Eastern Virginia Medical School, and President-elect of ABEM.
Here’s a link to the first article in this two-part series

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Why I will be an Emergency Medicine Physician

Why I will be an Emergency Medicine Physician

 

By Joey Leary – LECOM- Bradenton Class of 2014

 

Living in rural Haiti before medical school was my introduction to the field of emergency medicine. Having studied the religion, politics, and culture of the country as an undergraduate anthropology student, my move to the city of Leogane, Haiti in order to volunteer for the University of Notre Dame’s public health initiative to eradicate lymphatic filariasis had context.  Further, Dr. Paul Farmer MD, acclaimed anthropologist and physician, had uprooted to this same region years ago. I intended to use my gap-year in a meaningful way which might later give me strength and perspective during my anticipated life as a physician. Today, four years later, it is with this attitude that I reflect upon the 2010 earthquake, and am thankful for my role in one of the most extraordinary tragedies of the century. In the absence of a functioning hospital or any doctors, I was looked to as a physician. The frustration and impotence I felt that day as a first responder has guided me toward a career in emergency medicine.

 

When the sun came up on Jan 13th, twelve hours after the first earthquake which immediately killed one hundred thousand and would be responsible for the deaths of one hundred and fifty thousand more, I considered how to be most useful.  I was exhausted after a sleepless night of walking and hitchhiking the twenty miles from Port au Prince to Leogane, the city which turned out to be closest to the quake’s epicenter. Once back, searching through a partially collapsed Hospital St. Croix looking for friends and trying to call home occupied my time, not sleep. With the destruction of the town’s only hospital, locals began laying the wounded and dead in a field in front of a nursing school, hoping for any sort of expertise. I decided that distributing water and ibuprofen from my first aid kit to a field filled with compound fractures, head injuries, deep lacerations, and amputations, to name a few of the horrific injuries, was the most practical and useful thing for me. When I met an American nurse practitioner, Michelle Sare – founder of Nurses for Nurses International, and was asked to amputate a finger and start splinting arms and legs, my perception amongst the wounded changed. Family members begged me frantically to do something as their loved ones slowly died from internal bleeding, respiratory failure, and renal failure. That day was remarkable in every sense of the word.

 

Two months of rotations in Memorial Hospital’s level one trauma center in South Bend, Indiana as a third year medical student confirmed my suspicion that emergency care is for me.  I couldn’t help but marvel whenever I would see a patient with an injury similar to one I saw in Haiti. The pride that I take in knowing how to treat these acute injuries when confronted a second time is immense. I feel like a wizard when I am able to relieve pain with several well calculated thrusts, a splint, or some well-placed lidocaine. I hope to have more of these skills at my disposal so there will not be a crisis that I am unqualified to respond to.

 

The most valuable opportunities that have come my way; a chance to volunteer in Haiti, a chance to study dengue fever in the amazon, a chance to work as a camp counselor in Colorado, have always been a result of my enthusiasm and hard work.  These qualities, in addition to my unique motivation born out of natural disaster, give me reason to believe that I would make a great emergency physician. Regardless of the matching service’s determination, the moment I step off the plane in Port au Prince this June after graduation, I will be an emergency medicine doctor.

 

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February audio is posted

This month’s Annals audio, a look at the national report card on EM, is now posted and available. Highlights:

-The American College of Emergency Physicians has released their comprehensive national and state-by-state report cards on the status of emergency medicine in the United States. We do a brief summary and review.

-The new College clinical policy on procedural sedation and analgesia.

Email any time at annalsaudio@acep.org, and download the audio to get the goods and stay up to date.

D&A

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ALIVE – AGAIN

ALIVE – AGAIN

By Bruce D Janiak, MD, FACEP

A 40-something female came into our ED with some confusion, low BP, and tachycardia. EKG and labs were normal, but she continued to deteriorate despite appropriate treatments. The cardiology fellow was with me when she arrested, and despite ACLS protocol, we were unsuccessful in our resuscitative efforts. She was pronounced dead.

As the cardiology fellow and I were discussing her case outside of the room, the monitor began to show a spontaneous rhythm. She regained a pulse and BP and was admitted. Later that day she arrested again and after unsuccessful efforts was pronounced dead (again)!

Then she revisited her Lazerus process and spontaneously recovered.

Some two weeks later she came to the ED to see me saying “Dr Janiak, thanks for your efforts. I could hear you guys talking about me during the whole resuscitative process”

(Yes, this really happened!)

 

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Annals audio, Jan 2014 is here

Sorry for delays, sometimes we get all technical…. But the January audio is here! Highlights:

-Cricothyrotomy techniques: a comparison
-Two hand versus one hand BVM ventilation, which one works best?
-Can looking at the RV with bedside ultrasound help diagnose PE?
-Surviving sepsis: an update
-Lit review: can febrile neutropenics go home?
-Late bleeding after crotalid envenomation: how often?

…and more!
Check out the audio, and email any time annalsaudio@acep.org.

David & Ashley

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